Can This Surgery Prevent or Delay Total Knee Replacement?

High tibial osteotomy (HTO) prevented total knee replacement (TKR) in nearly 80% of patients with osteoarthritis (OA) of the knee after 10 years, according to a study.

“High tibial osteotomy is a knee surgery aimed at younger patients in the earlier stages of knee osteoarthritis. One of its goals is to prevent or delay the need for knee replacement,” said study author Trevor Birmingham, PhD, Canada Research Chair in the Faculty of Health Sciences and the Bone and Joint Institute at Western University, London, Ontario, in a press release. “In some ways, it’s like performing a front-end alignment on your car to stop asymmetric wear on your tires and increase their longevity.”

Dr. Birmingham and his fellow study authors assessed patients with OA of the knee who underwent medial opening wedge HTO from 2002 to 2014; the cumulative incidence of TKR was evaluated in July 2019, using orthopedic surgery reports and knee radiographs in the patients’ electronic medical records. The primary outcome was TKR. Multivariable Cox proportional hazards analysis was used to evaluate possible preoperative factors associated with conversion to TKR, including radiographic disease severity, malalignment, correction size, pain, sex, age, body mass index (BMI), and year of surgery.

A total of 556 patients underwent 643 HTOs. The five-year cumulative incidence of TKR was 5% (95% confidence interval [CI], 3-7), and 10-year incidence was 21% (95% CI, 17-26).

Preoperative predictors of TKR risk were radiographic OA severity (adjusted hazard ratio [HR], 1.96; 95% CI, 1.12-3.45), pain (adjusted HR, 0.85; 95% CI, 0.75-0.96), female sex (adjusted HR, 1.67; 95% CI, 1.08-2.58), age (adjusted HR, 1.50 per 10 years; 95% CI, 1.17-1.93), and BMI (adjusted HR, 1.31 per 5 kg/m2; 95% CI, 1.12-1.53).

Lead study author Codie Primeau said that HTO may be a good option for younger patients with less severe joint damage who are more active, noting that this population of patients makes up a significant portion of knee OA patients. “There is a treatment gap between exhausting nonoperative treatments and appropriateness for joint replacement, resulting in many years of pain, lost productivity and associated costs,” he added.

The study was published in CMAJ (Canadian Medical Association Journal).

“Given these findings, high tibial osteotomy may be underused in Canada and could be performed more often to delay or prevent the need for total knee replacement,” said study coauthor Robert Griffin, PhD, professor of surgery at Western University’s Schulich School of Medicine & Dentistry and the Bone and Joint Institute.